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Abstract: Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging. Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility. Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility. Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010. Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). Benefits, harms, and costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology. [Copyright &y& Elsevier]

Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management,and to review investigations in the assessment of ovarian aging.Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility.Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010.Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).Benefits, Harms, and Costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology. [ABSTRACT FROM AUTHOR]

Background: Bi-directional communication between the follicle and oocyte is necessary to regulate follicle and oocyte development. Currently, it is not practical to monitor the serial growth of individual follicles during assisted reproduction. The ovarian stimulation phase length (SPL) is an indirect measure of mean follicular growth rate. The objective of this study was to test the hypothesis that a short or long SPL would be associated with suboptimal outcomes in women undergoing in vitro fertilization (IVF). Materials and Methods: A retrospective cohort study was conducted in 140 women who underwent IVF. Follicle development was monitored every 2-3 days during ovarian stimulation using transvaginal ultrasonography. Once > 3 follicles reached ≥ 17 mm, human chorionic gonadotropin (hCG) was administered. Oocyte retrieval was performed approximately 35 hours after hCG. Oocytes underwent IVF on the day of collection and were evaluated daily thereafter. Embryos were transferred on days 3 or 5, depending on the number and quality of embryos available. Associations between SPL, age, follicle, oocyte, embryo and pregnancy outcomes were evaluated (SPSS version 17.0; SPSS Inc., Chicago, IL, USA). Results: A SPL of 11 days was associated with an optimal number of follicles that developed to ≥ 6 mm, ≥ 10 mm and ≥ 15 mm; serum estradiol concentrations; and number of oocytes collected (p<0.05). Gradual reductions in the number of developing follicles, serum estradiol concentrations and number of oocytes collected occurred with SPL less than or greater than 11 days (p<0.05). The SPL did not influence endometrial, embryo or pregnancy outcomes (p>0.05). Associations between SPL and outcomes were not influenced by age (p>0.05). Conclusion: The ovarian SPL can be used to predict the number of follicles that develop, oocytes collected and serum estradiol concentrations, but not embryo or pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Gestational trophoblastic neoplasia (GTN) is primarily a disease of women of reproductive age. In most instances, it is cured by surgical evacuation of the uterus, with persistent disease being very sensitive to chemotherapy. Hysterectomy, recommended for persistent chemotherapy-resistant uterine disease, may be unacceptable to the woman who wishes to maintain her fertility. Uterine resection of localized disease, with uterine reconstruction, may be a viable alternative. A case is presented of a woman with persistent uterine GTN, treated with localized uterine resection and reconstruction, followed by two successful pregnancies and deliveries. The literature is reviewed and potential pregnancy complications of this management, particularly uterine rupture, are discussed. [ABSTRACT FROM PUBLISHER]

Discusses the effects of the menstrual cycle on medical conditions. How menstrual cyclicity can be disrupted; In-depth look at a normal menstrual cycle; Evidence of a connection between estrogen withdrawal and migraine headaches; Treatment for menstrual migraine.

Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging., Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility., Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility., Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010., Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table)., Benefits, Harms, and Costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology., Recommendations: 1. Women in their 20s and 30s should be counselled about the age-related risk of infertility when other reproductive health issues, such as sexual health or contraception, are addressed as part of their primary well-woman care. Reproductive-age women should be aware that natural fertility and assisted reproductive technology success (except with egg donation) is significantly lower for women in their late 30s and 40s. (II-2A) 2. Because of the decline in fertility and the increased time to conception that occurs after the age of 35, women > 35 years of age should be referred for infertility work-up after 6 months of trying to conceive. (III-B) 3. Ovarian reserve testing may be considered for women ≥ 35 years of age or for women < 35 years of age with risk factors for decreased ovarian reserve, such as a single ovary, previous ovarian surgery, poor response to follicle-stimulating hormone, previous exposure to chemotherapy or radiation, or unexplained infertility. (III-B) 4. Ovarian reserve testing prior to assisted reproductive technology treatment may be used for counselling but has a poor predictive value for non-pregnancy and should be used to exclude women from treatment only if levels are significantly abnormal. (II-2A) 5. Pregnancy rates for controlled ovarian hyperstimulation are low for women > 40 years of age. Women > 40 years should consider IVF if they do not conceive within 1 to 2 cycles of controlled ovarian hyperstimulation. (II-2B) 6. The only effective treatment for ovarian aging is oocyte donation. A woman with decreased ovarian reserve should be offered oocyte donation as an option, as pregnancy rates associated with this treatment are significantly higher than those associated with controlled ovarian hyperstimulation or in vitro fertilization with a woman's own eggs. (II-2B) 7. Women should be informed that the risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age. Women should be counselled about and offered appropriate prenatal screening once pregnancy is established. (II-2A) 8. Pre-conception counselling regarding the risks of pregnancy with advanced maternal age, promotion of optimal health and weight, and screening for concurrent medical conditions such as hypertension and diabetes should be considered for women > age 40. (III-B) 9. Advanced paternal age appears to be associated with an increased risk of spontaneous abortion and increased frequency of some autosomal dominant conditions, autism spectrum disorders, and schizophrenia. Men > age 40 and their partners should be counselled about these potential risks when they are seeking pregnancy, although the risks remain small. (II-2C).

Objective: To review the use of hormonal replacement therapy (HRT) after treatment of breast cancer., Options: The effect and role of estrogens on breast cancer., Outcome: Improved health and quality of life for women with breast cancer., Values: References were collected through MEDLINE searches up to 2002., Evidence: The level of evidence and quality of recommendations have been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination., Benefits, Harms, and Costs: Utilization of the information to make a proper risk-benefit assessment of HRT use in women with breast cancer., Recommendations: 1. HRT after treatment of breast cancer has not been demonstrated to have an adverse impact on recurrence and mortality.(II-2B) 2. HRT is an option in postmenopausal women with previously treated breast cancer.(II-2B) 3. Prospective, randomized clinical trial results are needed.(III-A) VALIDATION: Recommendations were reviewed and revised by the Breast Disease Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the Executive and Council of the SOGC., Sponsor: The Society of Obstetricians and Gynaecologists of Canada.

Objective: To review family physicians' role in investigation and management of infertile couples., Quality of Evidence: MEDLINE and PubMed were searched using the MeSH headings infertility, advanced maternal age, polycystic ovarian syndrome, clomiphene citrate, and insulin sensitizers. Bibliographies of review articles and textbooks were also searched. Review articles, randomized trials, observational studies, and case series are cited., Main Message: Approximately 8% of Canadian couples have difficulty conceiving. Mother's age significantly affects ability to conceive. Infertility assessment focuses on ovulatory dysfunction, tubal factors, sexual factors, and male factors. Women older than 35 years more than 12 months infertile; women younger than 35 more than 18 months infertile; women likely to have such problems as anovulation, tubal disease, or endometriosis; women whose partners' semen tests abnormal; and women who request referral should be referred. Patients treated with clomiphene citrate should be aware of its potential side effects., Conclusion: Family physicians have an important role in preconception counseling. Detailed and focused assessment facilitates initial investigations and treatment and can identify couples who could benefit from referral for further assessment.